Provider Demographics
NPI:1013237163
Name:DAVIS, HEATHER NICOLE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 W HOWARD LN
Mailing Address - Street 2:L
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6300
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:
Practice Address - Street 1:605 NE 9TH ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TX
Practice Address - Zip Code:78957-1025
Practice Address - Country:US
Practice Address - Phone:512-360-5272
Practice Address - Fax:512-360-3060
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX724111363LF0000X
TXAP119076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308799101Medicaid
TX308799101Medicaid